THE 
PIGMENTARY SYPHILODERM. 
BY I. EDMONDSON ATKINSON, M. D„ 
PHYSICIAN TO THE BALTIMOHE SPECIAL DISPENSARY. 
(Read before the American Dermatological Association, at Saratoga Springs, N. Y. 
August 27th, 1876.) 
Reprinted from the Chicago Medical Journal and Examiner for October, 1878. 
CHICAGO: 
Bulletin Printing Company, 113 Madison Street. 
1878. THE PIGMENTARY SYPHILODERM. 
By I. Edmondson Atkinson, M. D., 
Physician to the Baltimore Special Dispensary. 
(Read before the American Dermatological Association, at Saratoga Springs, N. Y., Aug. 21th, 1878. 
Before presenting the cases whose histories form the basis of 
this paper, I may be pardoned for briefly reviewing the characters 
of the lesion of which I desire to speak. 
In describing “ syphilide pigmentaire ” for the first time in 
1853, Hardy ascribed to it peculiarities separating it from all 
other syphilodermata upon the one hand, and upon the other 
from the various forms of non-specific pigmentary abnormalities 
of the skin. The very lucid and faithful account of the 
symptoms of this lesion given by this author, has been supple- 
mented by other writers, but has more especially received sup- 
port from the pen of Fournier (Lemons sur la Syphilis etudids 
plus particulierement, chez la Femme, 1873, p. 422). Accord- 
ing to these authors, the pigmentary syphiloderm may appear 
from the fourth month to the end of the second year of the dis- 
ease, and is consequently one of its later secondary manifesta- 
tions. It is observed almost exclusively in the female sex, 
occupying preferably the skin of the neck (29 times in 30, 
Fournier), although occasionally met with upon other portions of 
the body. Its symptoms are, briefly, as follows : Upon the 
neck, more commonly upon its lateral surfaces, appear, with or 
without concomitant symptoms, but invariably subsequent to 
other manifestations of general syphilis of other parts of the 
body (roseola, papules, mucous patches, adenopathies, etc.), faintly 2 
colored spots, varying in size from that of a split pea to that of a 
finger nail, which rarely remain discrete, but rather run together, 
being connected by more or less narrow bands of similar dis- 
coloration, and forming an extent of pigmented surface resem- 
bling a clumsy network whose meshes are represented by areas 
of normal skin, or following Hardy and others, of skin whiter 
than normal (Legons sur la Scrofule et les Scrofulides et sur la 
Syphilis, et les Syphilides, 1864, p. 175). The color of the pig- 
mented area is of a very faint grayish-yellow, a caf£-au-lait color, 
paler than that of tinea versicolor or than that of chloasma 
uterinum. Fournier compares the effect to the dirty necks of 
uncleanly people. It is uninfluenced by pressure. 
The borders of the patches lose themselves more or less imper- 
ceptibly in the healthy skin. Their surface is smooth, absolutely 
without desquamation, not at all elevated above the general sur- 
face, giving rise to no subjective symptoms, and quite rebellious 
to treatment, whether anti-syphilitic or otherwise, enduring for 
months—it is even said for years. 
Such, then, being a general outline of this lesion, I propose to 
offer the following cases as illustrating it, before proceeding to 
discuss the claims upon which it rests its position in the nosology 
of syphilis. 
Case 1. Hannah F., white, 17 years old, unmarried, of 
medium size and complexion inclining to brunette, with dark hair 
and eyes, came to the dispensary June 10th, 1875. She said 
that during the previous summer she had had suppurating buboes 
in both groins (the scars of which are at present visible). 
Shortly after this she had sores upon her vulva, and five months 
ago an eruption first came upon her skin. Upon examination, 
her labia majora and minora were found to be very oedematous 
and infiltrated from the irritation of numerous mucous patches, 
which also extended along the perineum. Over her thighs and 
abdomen were the stainings left by a previous syphilitic eruption. 
Mucous patches were present upon the faucial mucous membrane. 
There was a general adenopathy, especially marked in the 
cervical region. Distributed over the neck and shoulders, and 
extending over the deltoid region of the arms quite symmetrically, 
were, what appeared upon superficial examination to be spots of 3 
abnormally whitened integument, scattered irregularly and dis- 
cretely over the surface. Upon more rigid examination, these 
spots, which did not exceed from six to twelve millimeters in 
diameter, were seen to be not whiter than normal, the true 
alteration being evidently in the surrounding portions of the skin. 
This alteration consisted of pigmented spots extending over the 
front and sides of the neck and shoulders, and connected with 
each other uninterruptedly, except where the patches of normal 
skin seemed to be inserted, forming the network-like appearance 
characteristic of the eruption. This maculation, which resembles 
in coloration a faint chloasma uterinum, is less pronounced than 
that of tinea versicolor, and also differs from that following the 
ordinary syphiloderms, being paler. The surface was perfectly 
smooth and free from desquamation. There was no itching. The 
patient was, however, much mortified at the dirty appearance of 
her skin, which, when first noticed by her a short while ago, was 
just as at present. She was of careful, cleanly habits, and was 
quite sure that there had been no alteration in the appearance of 
the eruption since it was first noticed. She was subjected to an 
appropriate mercurial internal and external treatment, which was 
followed with considerable regularity. Upon July 24th, it was 
noted that the treatment had effected the disappearance of all the 
mucous patches except one at the fourchette, and that the labia 
were becoming much less infiltrated. The maculation about the 
shoulders and neck persisted, though fainter. She was under 
treatment steadily until August 11th, the maculations becoming 
fainter, and general improvement being steadily experienced. 
She was not seen again until January 25th, 1876, when she 
informed me that she was married and three months pregnant. 
Upon examination, she appeared quite well, the infiltration of 
the labia having quite disappeared, as well as the maculations 
upon her neck and shoulder. She did not again come under 
observation. 
Case 2.—June 19th, 1877, Becky H., a young prostitute, 
born in Pennsylvania, 19 years old, of moderately fair com- 
plexion, with blue eyes and light hair, and of healthy appear- 
ance, applied at the dispensary to be treated for a vaginal dis- 
charge of three weeks’ duration. She said she had had a similar discharge during the previous January. Upon physical examina- 
tion, the integument of her abdomen and chest anteriorly, and of 
her thighs, was well sprinkled with a fading roseola. Thei'e 
were no signs of an ulcer upon the genital organs, but there was 
a painless inguinal adenopathy. She was kept under close 
observation until July 7th. She re-applied October 23rd, com- 
plaining of pharyngeal mucous patches, but without any cutane- 
ous eruption. December 8th. The mucous patches which had 
healed, had now returned. December 29th. Having now been 
at least seven months syphilitic, it was now noted that upon both 
sides of her neck, arranged with tolerable symmetry, were a 
number of faintly brownish spots, similar in coloration to those 
of the previous patient. They were limited to the sides of the 
neck, and did not inclose unpigmented areas, not being connected 
so as to form the usual network. She had been almost con- 
stantly under my observation, and neither she nor I had observed 
a previous eruption upon these parts. She quite decidedly denied 
that any such had been present. There were no subjective 
symptoms, and the spots were smooth, unelevated, and not 
desquamating. Their margins wrere not very well defined. By 
February 19th, the maculations were much fainter, but had 
undergone no change in distribution. March 3rd. There had 
been for several days a right iritis. The maculations had not 
diminished in size or configuration ; they had simply faded, and 
more nearly approached the normal hue of the skin. During all 
this period, the patient was almost constantly undergoing a mer- 
curial treatment. She has not again come under observation. 
My third case was an anomalous one in several particulars, 
and I have hesitated before including it with cases of pigmentary 
syphiloderm, having never seen a similar condition ; but upon 
reflection I am unable to assign it to any other form of syphilitic 
eruption than the one under consideration. It is as follows, 
viz. : 
Case 3.—Annie J. came to the dispensary October 10th, 
1875. She was a light mulatto, 18 years of age, and of a 
moderately healthy appearance. At the posterior commissure of 
the labia minora there was a soft spreading ulcer, accompanied 
by indolent inguinal adenopathy. She had, also, some sore throat, enlargement of the cervical glands, and complained of 
pains in the arms and sides. No reliable history could be 
obtained, although it was evident that the lesions were of some 
duration. The sore was cauterized with the acid nitrate of 
mercury. She did not again appear at the dispensary until 
March 28th, 1876, five months after her first appearance. She 
then said that her eyes had been troubling her for about two 
months. This was found to be due to a double iritis ; and there 
was a small perforation of the left cornea, through which the 
iris slightly protruded. Upon the thighs was a fading papular 
eruption. Upon the dorsal surfaces of the hands and wrists, and 
upon the inner and extensor surfaces of the knees, were very 
symmetrically arranged mottled appearances, resembling, when 
seen at a distance, old scars from burns, but really due to pig- 
mentary changes alone. According to her, they had been present 
nearly all winter. As in my first case, my first impression was 
that the lighter-colored islets were the affected portions, but a 
moment’s careful examination served to correct this error. These 
areas, which varied in size from five to fifteen millimeters in 
diameter, were of the color of the normal skin, and only 
appeared lighter by contrast with the surrounding darker sur- 
face, which was almost black, and extended continuously, the 
different spots being connected by narrow bapds, and forming the 
lace-like arrangement already spoken of. The borders were 
abruptly margined. The normal caffi-au-lait color of the general 
surface contrasted strikingly with the hyper-pigmented portions, 
the general effect seemingly justifying the term piebald in 
describing it. No other portion of the skin was similarly affected. 
She was last seen May 31st, when, after taking cod liver oil and 
the syrup of the iodide of iron, she was much better. The 
maculations had faded from her hands, but were still present 
upon the inner surfaces of both knees. 
The pigmentary changes of which the foregoing cases afford 
examples are so unfrequently observed that many writers have 
been led to deny that they -are to be considered direct results of 
syphilis. The insignificance of the symptoms, and the proba- 
bility of its being frequently overlooked must, however, be con- 
sidered. Dr. G. IT. Fox, who, however, regards the lesion as a 6 
vitiligo, very properly draws attention to this point (Amer. 
Journ. Med. Sciences, April, 1878), and thinks that it will 
much more frequently be observed, when searched for, even in 
the male sex. On the other hand, there is danger that there 
may be committed the error of including with the pigmentary, 
syphiloderm, lesions of variously different origins. These are 
principally the chloasmata, chloasma uterinum, and chloasma 
cachecticorum, and the stainings left behind by a roseola 
syphilitica. (It is hardly necessary here to refer to the danger 
of confounding tinea versicolor wTith the pigmentary syphiloderm, 
since the points of a differential diagnosis are always at hand in 
the presence of a parasite in the desquamated epidermis of the 
former.) The ordinary chloasmata may usually be distinguished 
by attention to their color, distribution and configuration, as well 
as to the constitutional conditions of the patients. Their color 
is usually darker ; they are more uniform in their distribution, 
not inclosing the mesh-like spaces, and are most rarely confined 
to the neck, the favorite seat of the lesion under discussion. 
(The chloasma that is seen frequently in old syphilitics, is simply 
due to the cachexia, and is altogether unlike the truly syphilitic 
form.) 
The stainings left behind by a syphilitic roseola, to my mind, 
more nearly approach, in their characteristics, the pigmentary 
syphiloderm, than any other form of lesion. It is not at all 
uncommon to see upon the abdomen especially, tracts of hyper- 
pigmented skin inclosing circular areas of normal color. These 
tracts are the remains of syphilitic roseola ; but here, however, 
there is usually the clear history of a preceding hyperaemia, the 
hyper-pigmentation is much more extensive, and its duration 
much less prolonged. The especial point of distinction, however, 
is that the pigmentary syphiloderm appears independently of any 
preceding hyperaemia, according to the almost universal opinion 
of those who have observed it, and to the unanimous opinion of 
the patients. Until convincing clinical proof of the necessary 
pre-existence of this hyperaemia is produced, those who believe 
in the reality of this syphiloderm are entitled to hold to their 
faith. 
There are others who, recognizing the fact that the pigmentary deposits are not due to preceding hypersemia, consider the non- 
pigmented areas, or, as they claim, the whitened patches, to be 
the seat of the true morbid process, and that the lesion is a pig- 
mentary atrophy of the inclosed spaces, around which there is 
an increased deposit of pigment, as is usually the case in acquired 
leucoderma. 
It is true that some writers, as Hardy and Drysdale, while 
considering the hyper-pigmentation to be the essential lesion, 
also think that these inclosed spaces contain less coloring matter 
than normal ; and admitting that this occasionally is the case, it 
becomes possible, in a narrow sense, to designate such condition 
as leucodermatous. But in doing this we simply beg the ques- 
tion, since the transient and always very limited blanching, is 
invariably accompanied by a hyper-pigmentation always equal- 
ing, almost always exceeding, it in extent, and which has at least 
equal claims to be considered the essential lesion. I think it 
especially unfortunate that Dr. George H. Fox, who has most 
ably expressed his view of the leucodermatous nature of this 
affection, should have used the term vitiligo to designate it, a 
term that has been pretty generally applied to that form of lesion 
where there is a permanent, complete and usually progressive 
centrifugal disappearance of cutaneous pigment. It is true that 
Dr. Fox is unwilling that vitiligo should be thus restricted in its 
meaning, but nevertheless, in describing it, he quotes Dr. 
Duhring’s definition of the condition, which certainly has refer- 
ence to a definite, progressive and permanent loss of pigment. 
It may be properly objected to the view that the supposed 
leucodermic patches occupy the sites of previous hypersemic 
eruptions, that it is the positive opinion of other writers, based 
upon their personal experience, that the pigmentary syphiloderm 
as observed by them, has never succeeded upon the site of an 
antecedent eruption. The leucodermatous condition, moreover, 
is certainly not present in all cases, and it is a fact, as observed 
by Hardy, and evidenced in my second case, that the hyper-pig- 
mented spots may occur without including islets of normal or 
whitened integument. 
The resistance offered by this lesion to the influence of anti- 
syphilitic remedies, undoubtedly affords their most efficient weapon to those who combat the doctrine of its syphilitic nature. 
It is, for example, argued that all syphilitic alteration, especially 
those of the earlier constitutional periods, are promptly antag- 
onized by the administration of mercury, and that the hyper- 
pigmentation under discussion, not being modified by this drug, 
cannot be a syphilitic manifestation. Such a conclusion is based 
upon incorrect ideas of the nature of the pigmentation. The 
pigmentary changes following the earliest syphilitic symptoms 
are always due to the pre-existing hypercemia—their duration 
and intensity are usually proportioned to the duration and 
character of the hyperaemia, and they are principally deposited 
in the connective tissue of the corium, in the region of the 
vascular distribution. The rationale of pigmentation is too little 
known, but we do know that pigment disappears readily after the 
recession of a hypersemia of short duration, while after an old 
eczema or chronic ulcer, it may remain for many years. Why 
this is so, is not known. It is a matter of universal clinical 
experience that the pigmentations following the early syphilitic 
eruptions are but little disposed to become permanent, and are 
readily re-absorbed. With the pigment substance of the 
epidermis, on the contrary, the case is different. Here the 
hyper-pigmentation may readily occur quite independently of 
hypersemia, and is due to an increase of the melarin, the physio- 
logical pigment of the skin. 
It is a matter of general experience that the non-vascular 
hyper-pigmentations are provokingly obstinate, and beyond the 
reach of internal medication. No one can explain why the 
different cachexite, or why uterine disorder should induce a 
hyper-pigmentation in the rete malpighii. There is no reason 
why the syphilitic dyscrasia, as distinct from any cachectic con- 
dition, may not equally evoke similar pigmentary changes, and 
with the light thrown upon the subject from time to time by cor- 
roborative cases, I have no hesitation in saying that it does evoke 
them, and venture to suggest that they may be amenable to the 
same therapeutic agencies. THE CHICAGO 
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